UUP Benefit Trust Fund DeltaCare USA (DHMO) Enrollment Form

Please fill out the form below to enroll electronically in the Benefit Trust Fund DeltaCare USA (DHMO) Program.

To enroll and complete a paper enrollment form HERE and you may email, fax, or mail to the UUP Benefit Trust Fund.

Fax: 1-866-559-0516 Mail: Benefit Trust Fund , PO Box 15143, Albany, NY 12212-9954 Email: Benefits@uupmail.org

The DeltaCare®USA DHMO plan is being offered to UUP-represented employees as an alternative dental option. In addition to the original Delta Dental PPO plan, DeltaCare®USA DHMO is an HMO-type dental program that is designed to encourage regular visits to the dentist by having no copayments on most diagnostic and preventive benefits.

Please note that the DeltaCare® USA DHMO Program has provider deficiencies in the following areas: Alfred, Canton, Cobleskill, Delhi, Oneonta, Plattsburgh, and Potsdam. Delta is making every effort to contract providers in these regions.

Employee Information:

*First name:  


*Last name:  

*Date of Birth:  

NYS Employee ID:  




*Zip Code:  

*Non-SUNY Email:  

Dental Office Information:

*Enrollee DeltaCare USA Primary Dentist:  

*Dental Office ID:  


Spouse \ Domestic Partner Information:
DeltaCare USA Primary Dentist:  

Dental Office ID:  

First name:  


Last name:  

Date of Birth:  

Dependent Children Information

Enter Dependent Children Information:   minus (HERE)

DeltaCare®USA DHMO Dentists: You must select a dentist that has contracted specifically with DeltaCare®USA DHMO. This dentist will serve as your primary care dentist. You can locate a DeltaCare dentist by calling Delta Dental Customer Service at 800-471-7093 or by visiting www.deltadentalins.com/uup.

New Employees: If you are a new employee, you can select DeltaCare®USA DHMO as your dental plan. If you do not select DeltaCare®USA DHMO, you will automatically be enrolled in the Delta Dental PPO plan.

Open Enrollment: UUP-represented employees who wish to switch to the DeltaCare®USA DHMO plan for the next calendar year may do so during the annual open enrollment period—Nov. 1-30. Enrollment forms can be accessed at www.uupinfo.org.

Dependent Coverage: You and your eligible dependents may receive care from the same contract dentist or, if you prefer, you may collectively select up to a maximum of three different dental facilities.

Dental Specialists: Your contract dentist will coordinate your specialty care needs for oral surgery, endodontics, periodontics or pediatric dentistry with an approved contract specialist. There is no additional charge to you for receiving care from a specialist.

Teeth Whitening: Bleaching is a benefit under the DeltaCare®USA DHMO plan.

*Acceptance of Terms

YES! I Agree that submission of this form constitutes your consent to online enrollment and your commitment to enrollment in the DHMO program for one year. The enrollment year goes from January 1st – December 31st of each year. You will receive an email confirming receipt of this enrollment form. Please retain a copy of that email for you records.

* Required

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